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Because the Surgeon General’s report provides an excellent discussion of the nature, diagnosis, and treatment of mental disorders, this report will focus instead on community-based servi

OLDER ADULTS AND MENTAL HEALTH:

ISSUES AND OPPORTUNITIES

Department of Health and Human Services

Administration on Aging

January 2001

TABLE OF CONTENTS

Foreword……….…….……… iii

Preface……….v

Acknowledgements……….……… ………vii

Executive Summary……….……… ix

Introduction……….1

Chapter I: Background……….…3

Chapter II: Community Mental Health Services……….….……… 21

Chapter III: Primary and Long-Term Care……….……… …27

Chapter IV: Supportive Services and Health Promotion…….……… 37

Chapter V: Medicare and Medicaid Financing of Mental Health Care….……… 55

Chapter VI: Challenges in Mental Health and Aging……….……… 61

References……….………… …67

Appendix A: Summary of Chapter 5, Mental Health: A Report of the Surgeon General 85

Appendix B: Resources on Mental Health and Aging……….… 87

FOREWORD

That the elderly population will burgeon in the coming decades is of no surprise to any of

us The quest to help Americans live longer, healthier lives has reaped enormous successes Certainly, the years ahead hold the promise of continued improvements in the standard of living for older Americans But length of years alone is not enough; we must continue to focus our efforts on making sure that the quality of life they enjoy is the best possible

As Mental Health: A Report of the Surgeon General pointed out, old age is a lively and

exciting time for many Americans But too many of our elders struggle to cope with difficult life situations or mental disorders that negatively affect their ability to participate fully in life The cost of this loss of vitality—to elders, their families, their caregivers, and our country is staggering Moreover, there is ample evidence that much of this suffering could be avoided if prevention and treatment resources were more adequately delivered to older Americans

It is in this spirit that this companion document to the Surgeon General’s Report is

presented Older Adults and Mental Health: Issues and Opportunities identifies some exciting

initiatives and formidable challenges in the field of mental health and aging Above all, this report makes clear that now is the time to alleviate the suffering of older people with mental disorders and to prepare for the growing numbers of elders who may need mental health services

It is my fervent hope that all of those who have a stake in the mental health of older people will view this report as a call to action, and will use it as a guide for progress It will take the aging network, mental health professionals, providers of community mental health services, long-term care facilities, researchers, policymakers, consumers and advocates working in concert

to bring forth a new day for those who suffer needlessly Only through collaborative efforts among all of these stakeholders and the Department of Health and Human Services can we enhance the well-being of older persons throughout the Nation

Jeanette C Takamura, Ph.D

Assistant Secretary for Aging U.S Department of Health and Human Services

PREFACE

I am very pleased that Older Adults and Mental Health: Issues and Opportunities has

been published as an important companion piece to the first-ever Surgeon General’s report on mental health The dawn of a new millennium bears witness to rapid improvements in health and health care in the United States The average life span of Americans has increased dramatically, and the population aged 85 and over has grown and will continue to grow well into the next century The majority of older Americans cope constructively with the many changes that accompany the aging process However, nearly 20 percent of the population aged 55 and older experience mental disorders that are not part of “normal” aging

Mental Health: A Report of the Surgeon General, the first-ever document of its kind

dedicated to mental health, discusses mental health and mental illness across the life span, including a chapter on older adults Mental illnesses are real health conditions A growing body

of scientific research has highlighted both the potentially disabling consequences of unrecognized or untreated mental disorders in late life, and important advances in psychotherapy, medications, and other treatments When interventions are tailored to the age and health status

of older individuals, a wide range of treatments is available for most mental disorders and mental health problems experienced by older persons, interventions which can vastly improve the quality of late life Despite this progress, stigma, missed opportunities to recognize and treat mental health problems in older persons, and barriers to care remind us that we still have a great deal of work to do

In recognition of the importance of assuring mental health for older Americans, a reprint

of the chapter of the Surgeon General’s report on mental health and older adults has been

released as a separate document As a companion piece, Older Adults and Mental Health:

Issues and Opportunities focuses on the broad range of community-based preventive and

treatment services that are available to older adults and their families This is a valuable resource for service providers, policymakers and researchers, for by building on these initiatives we can begin to address the many challenges that face us in mental health and aging

I greatly appreciate the vision and leadership of Dr Takamura and the Administration on Aging as we work together for the mental health of older Americans

David Satcher, M.D., Ph.D

Surgeon General U.S Public Health Service

ACKNOWLEDGEMENTS

This report was prepared by the

Administration on Aging The Assistant

Secretary for Aging, Dr Jeanette Takamura,

and the Deputy Assistant Secretary for

Aging, Diane Justice, provided guidance and

encouragement throughout to the author, Dr

Peggy L Halpern

At the beginning of the project, valuable

input was obtained from experts who

participated in three separate telephone

conference calls Experts in the field of

aging who participated in the first call

included: Carol Cober, AARP; Sara

Aravanis, National Association of State

Units on Aging; David Turner, Salt Lake

County Aging Services; and Mary

Burgger-Murphy, National Council on Aging

Mental health experts who participated in

the second call included: Willard Mays,

National Coalition on Mental Health and

Aging; Todd Ringelstein, National

Association of State Mental Health Program

Directors and Office of Community Mental

Health Administration in New Hampshire;

Dr Gary Gottlieb, Harvard Medical School

and Partners Psychiatry and Mental Health

System; Jim Stockdill, WICHE Mental

Health Program; Eileen Elias and Jennifer

Fiedelholtz, Substance Abuse and Mental

Health Services Administration; Bernie

Seifert, Mental Health Center of Greater

Manchester; and Hikmah Gardner, Mental

Health Association of Southeastern

Pennsylvania

The researchers who participated in the third

call included: Dr Lenard Kaye, National

Association of Social Workers and Bryn

Mawr College; Ray Raschko, American

Society on Aging; Dr John Colletti,

American Psychological Association; Dr

Forrest Scogins, University of Alabama;

Leslie Curry, American Geriatrics Society; and Christine deVries, American Association for Geriatric Psychiatry

There were also many who kindly provided information as the report was developed Some of these persons include: Robin Bracey, IONA Senior Services, Washington D.C.; Theresa Conley, Human Services Research Institute, Cambridge, Massachusetts; Dr Olinda Gonzales, Center for Mental Health Services, SAMHSA; Marilyn Lange, Village Adult Services, Milwaukee; Sister Edna Lonergan, St Ann Center for Intergenerational Care, Milwaukee; Dr Barry Lebowitz, National Institute of Mental Health; Noel Mazade, National Association of State Mental Health Program Directors Research Institute; Anita Rosen, Council on Social Work Education; Andrea Sheerin, National Association of State Mental Health Program Directors; and Drs Joyce Berry and Paul Wohlford, Center for Mental Health Services, SAMHSA

The following staff members of the Administration on Aging reviewed the report and provided invaluable comments: Melanie Starns, Edwin Walker, Saadia Greenberg, Carol Crecy, Harry Posman, Christine Murphy, Bruce Craig, Sunday Mezurashi, Diane Justice, and Dr Jeanette Takamura Also, during the initial phases of the project, Jennifer Watson provided invaluable assistance in searching for and locating appropriate research publications and in arranging the teleconference calls Theresa Arney provided a major source of assistance in obtaining research publications and Bruce Craig and Evelyn Yee were also helpful in obtaining reference materials Finally, special thanks to Holly Baker Schumann for shepherding this report through its final phases

EXECUTIVE SUMMARY

The design and delivery of mental health

services to older persons is a vital societal

challenge, in light of the enormous increase

in the elderly population that is projected to

occur during the first half of this century

The purpose of this report is to highlight

major issues in the field of mental health and

aging; to discuss efforts to address these

issues, including community-based services;

and to identify the crucial challenges that

must be confronted in the years ahead and

strategies to meet them

This report is written as a companion

document to Mental Health: A Report of the

Surgeon General (USDHHS, 1999a)

Because the Surgeon General’s report

provides an excellent discussion of the

nature, diagnosis, and treatment of mental

disorders, this report will focus instead on

community-based services that can be

utilized by a wide range of elders, including

older persons in good mental health, for

whom outreach and education might be

helpful; older persons who are experiencing

acute stress or crisis; and those with severe

mental disorders While substance misuse

and abuse are closely intertwined with

mental health and merit full discussion, the

primary focus of this report is on mental

health and aging and the services and

systems designated to deal with these areas

of concern

Mental health and supportive services must

address more effectively the ethnic and

racial diversity of our older population A

supplement to Mental Health: A Report of

the Surgeon General that will address

mental health and ethnic minorities is in

preparation The need for and use of mental

health services by distinct ethno-cultural

groups over the life span, including a discussion of service use by older adults, is the domain of this second, much-anticipated supplement

This companion document on mental health and aging consists of six major sections Each of these sections is summarized below

Introduction and Chapter 1:

Background

Demographic characteristics The elderly

population is projected to grow rapidly between 2010 and 2030 as the 76 million

“baby boomers” reach 65 years of age By

2030, older adults will account for 20% of the nation’s people, up from 13% today Simply by virtue of the growth of the older population, the need for geriatric mental health services will increase In addition to being larger in number, the older adult population will be much more diverse with regard to generational cohorts, gender, minority status, income, living arrangements, and physical and mental health

Stressors and adaptations During the

normal process of aging, older persons encounter stressors that may trigger both appropriate and distorted emotional responses Two of the most stressful unplanned life events include declines in health and loss of loved ones In addition, chronic strains may also impact the older adult; for example, strains within the community, in relationships, or in the older person’s immediate environment are all stressors Most older persons are able to adapt to these changes and maintain their well-being by marshaling their personal and

environmental resources These include

coping skills, social support, and

maintaining a sense of control

Service delivery issues While there are

substantial needs for mental health services,

older adults have made very limited use of

these services The reasons for this

underutilization include: denial of problems,

reluctance to self-refer, failure by

professionals to identify the signs and

symptoms of mental illness, and access

barriers At the systems level, lack of

collaboration between agencies and systems,

funding issues, gaps in services, and

shortages of mental health personnel trained

in aging and aging professionals trained in

mental health can affect access to and

provision of appropriate services

Mental Health and Aging Most older adults

enjoy good mental health, but nearly 20% of

those who are 55 years and older experience

mental disorders that are not part of normal

aging The most common disorders, in order

of prevalence, are anxiety disorders, such as

phobias and obsessive-compulsive disorder;

severe cognitive impairment, including

Alzheimer’s disease; and mood disorders,

such as depression Schizophrenia and

personality disorders are less common

However, some studies suggest that mental

disorders in older adults are underreported

The rate of suicide is highest among older

adults compared to other age groups

Older adults with mental illness vary widely

with respect to the onset of their disorders

Some have suffered from serious and

persistent mental illness most of their adult

life, while others have had periodic episodes

of mental illness A substantial number

experience mental health disorders or

problems for the first time late in life—

problems which are frequently exacerbated

by bereavement or other losses which tend

to occur in old age Yet another variable is severity Mental disorders can range from problematic to disabling to fatal Mental health services must be designed to meet the needs of older people at all points of the mental health continuum However, the assessment, diagnosis and treatment in mental disorders among older adults present unique difficulties that must be contended with Further efforts aimed at the prevention

of mental disorders in older adults are also needed

Delivery of mental health services to older adults Older Americans underutilize

mental health services A number of individual and systemic barriers thwart the provision and receipt of adequate care to older persons with mental health needs These include the stigma surrounding mental illness and mental health treatment; denial of problems; access barriers; fragmented and inadequate funding for mental health services; lack of collaboration and coordination among primary care, mental health, and aging services providers; gaps in services; the lack of enough professional and paraprofessional staff trained in the provision of geriatric mental health services; and, until recently, the lack

of organized efforts by older consumers of mental health services

Initiatives in mental health and aging While

critical challenges and service delivery issues exist, there have been a number of notable endeavors and initiatives to address these issues Among these are efforts to encourage collaboration in the delivery of mental health and supportive services; organize consumer advocacy groups; heighten public awareness of mental health issues; support research specific to older adults with mental health needs; and expand and better educate the geriatric mental health workforce These efforts provide an

excellent foundation for confronting critical

challenges in mental health and aging

Chapter 2: Community Mental

Health Services

It is estimated that only half of older adults

who acknowledge mental health problems

receive treatment from any health care

provider, and only a fraction of those receive

specialty mental health services The

specialty mental health services system

consists of private mental health providers

funded by private insurance and consumers,

and publicly and privately owned providers

funded by states, counties, and

municipalities Institutional or

facility-based mental health services include

inpatient care (acute and long-term),

residential treatment centers, and therapeutic

group homes Community-based services

include outpatient psychotherapy, partial

hospitalization/day treatment, crisis services,

case management, and home-based and

“wraparound” services

Historically, public and private funding for

adult mental health services was targeted

toward intensive and costly institutional

care In the last two decades, due mainly to

court decisions restricting the

institutionalization of adults with mental

illness, the service priorities have changed in

favor of less intense community-based

services

Most mental health funding comes from

state and local governments, Medicaid, and

private insurance Publicly funded services

are thought to be a “safety net” for those

unable to afford private insurance or to pay

for services The federal government

augments state and local funding through the

Community Mental Health Services Block

Grant (CMHSBG) The CMHSBG is a joint

Federal-state partnership that awards annual

formula grants to the states to provide community-based mental health services to adults with serious mental illness and children with serious emotional disturbance The Substance Abuse and Mental Health Services Administration’s (SAMHSA) Center for Mental Health Services administers the CMHSBG Each state has a state mental health authority whose mission

it is to oversee the public mental health system In order to receive CMHSBG funds, each state must have a comprehensive plan to provide mental health services throughout the state States vary widely in the organization of their mental health service delivery systems, and in the degree

to which these systems interact with providers of other types of services—e.g., primary care, social services, and the aging network

Access to community-based mental health services is problematic for older people because of several factors, including the growing reliance on managed care; the targeting of mental health services to specialized groups that exclude the elderly; and the emphasis public providers place on serving the severely chronically mentally ill

In addition, community mental health organizations often lack staff trained in addressing non-mental health medical needs, which are especially important for older adults These organizations also tend not to see treatment of those with cognitive impairments as part of their mission

Survey findings indicate that while older adults have a tremendous need for services such as elder case management or psychiatric home care services, only a few states designate older adults as priority clients and only a minority of the states address the mental health needs of the elderly through specialized services for them However, studies have also shown

that the use of specialized geriatric services

and staff as well as partnerships between the

aging and mental health systems can

increase access to services for older persons

Chapter 3: Primary and

Long-Term Care

Primary care When faced with a mental

health problem, older persons frequently

first turn to their primary care physician

Over half of older persons who receive

mental health care receive it from their

primary care physician Many reasons have

been suggested for this pattern: going to a

primary care physician does not carry the

same stigma that specialty mental health

services do; insurance policies encourage

use of primary care; and primary care may

be more convenient and accessible

While many older people prefer to receive

mental health treatment in primary care

settings, diagnosis and treatment of older

persons’ mental disorders in these settings

are often inadequate Many primary care

physicians receive inadequate training in

mental health Physicians often attribute

psychiatric symptoms either to changes

expected with age or concomitant physical

disorders and sometimes inappropriately

prescribe psychotropic medications In

addition, some physicians’ negative attitudes

toward older people appear to undermine

their clinical effectiveness

There are also system barriers to providing

mental health care in the primary care

setting It is important to coordinate mental

and physical health care, because consumers

with emotional problems can also have

physical health problems However,

frequently this coordination does not occur

In response to these shortcomings, several

models aimed at improving mental health

services in primary care have been developed These models call for either collaboration between mental health and primary care providers, or integration of mental health providers into the primary care setting Currently, there are three ongoing multi-site research efforts in the United States that are examining services to older persons with mental health problems

in primary care settings

Long-term care Various studies indicate a

high prevalence of mental illness in nursing homes Dementia and depression appear to

be the most common mental disorders in this setting However, most residents with mental disorders do not receive adequate treatment Barriers to good treatment include: (1) a shortage of specialized mental health professionals trained in geriatrics; (2) lack of knowledge and inadequate training

of nursing home staff about mental health issues; (3) lack of adequate Medicaid and Medicare reimbursement to facilities to cover behavioral and mental health problems; and (4) difficulty obtaining the services of psychiatrists and other mental health professionals due to inadequate reimbursement policies Thus, there is a great need to incorporate mental health care into the basic structure of nursing home care and to make professional services available

to patients and their families

Psychosocial interventions that can be used

in nursing homes include individual, group, program, family-based and staff interventions Each intervention focuses on helping the resident and/or the family adapt

to the nursing home environment, changing resident behaviors, improving quality of life,

or enhancing staff and resident morale These are described and discussed in detail

Chapter 4: Supportive Services

and Health Promotion

This chapter describes a number of

supportive services and health promotion

activities that may be helpful to older people

with mental disorders and their families

Examples of each are provided and research

findings on the effectiveness of each service

are reviewed

In planning for the delivery of mental health

services, it is clear that alternatives to

specialty mental health settings must be

considered given the stigmatization of

mental health services in the minds of many

older adults Senior centers, congregate

meal sites, and other community settings

that older people frequent and feel

comfortable in may offer promising venues

for the delivery of mental health services to

seniors Hence, it is essential that the aging

network, the mental health system, and

primary health care providers form

partnerships to explore how to best marshal

their various resources in the service of

older persons’ mental health

Among the services discussed are:

§ Adult day services are group programs

designed to respond to the needs of

functionally and/or cognitively impaired

adults These programs provide older

adults with social interaction and health

monitoring and also provide respite for

caregivers;

§ Health promotion and wellness

programs focus on educating older

adults about how to increase control over

and improve their mental health,

nutrition, or physical exercise They

seek to promote mental health and

prevent the onset of mental disorders and

costly treatment

§ Mental health outreach programs offer

early identification and interventions to encourage access to services for high-risk older adult populations They offer assessment and referral to community treatment and support services These programs strive to keep older persons in the community by providing supportive services that help to increase functioning;

§ Support groups and peer counseling

programs provide preventive

interventions Support groups have members who share similar problems and pool resources, gather information, and offer mutual support Peer counseling programs utilize the skills and life experiences of older persons as peers to enable others at risk to be supported and helped Both of these interventions provide psychosocial support to older people facing life transitions, short-term crises, or chronic stressors

§ Caregiver programs, which offer a range

of services for caregivers of frail elders such as respite care, support groups, care management, counseling, or home modifications These services can reduce caregiver stress and improve coping skills so that families can continue to provide care; and

§ Respite care refers to a range of services

that offer temporary relief to caregivers

of frail elders, such as short periods of companionship in the home or short stays in residential settings Respite programs can prevent or alleviate depression and burnout, delay the need for more costly care, and offer an opportunity for mental health outreach

by bringing the family into short-term

contact with formal care delivery

systems

Chapter 5: Medicare and

Medicaid Financing of Mental

Health Care

Basic Medicare mental health benefits are

reviewed, including inpatient psychiatric

care, outpatient mental health services, and

partial hospitalization The most important

issues in Medicare’s mental health coverage

are identified as: lack of prescription drug

coverage, different co-payments for mental

health services, limited coverage of

community-based services, and a limit on

inpatient specialty psychiatric care

Mandatory and optional Medicaid coverages

are also summarized as well as the most

important issues in this program, including

uneven optional benefits among states and

reimbursement policies which sometimes

make provision of mental health services

problematic

Chapter 6: Challenges in

Mental Health and Aging

The areas of mental health and aging are not

without challenges and opportunities These

include challenges related to:

§ Prevention and early intervention

Existing efforts generally focus on the

diagnosis and treatment of illness rather

than on the early identification of

high-risk individuals and families, preventive

measures, and the promotion of optimal

health;

§ Public awareness and education

Stigma discourages older adults and

their family members from

acknowledging mental health problems

It also discourages the pursuit of

treatment Societal stereotypes and

myths can hinder efforts to diagnose and

treat mental illness

§ Workforce issues: shortages and need

for education There is an insufficient

supply of trained professionals and paraprofessionals available to provide mental health services to older people Training opportunities for those entering and currently working in the field must include multidisciplinary cross-training;

§ Financing mental health services

Federal, state, and private funding streams are separate, may not be coordinated, and tend to be less than adequate A prescription drug benefit

for seniors under Medicare is needed;

§ Collaboration The delivery system

encompasses a variety of distinct care systems at both the institutional and community levels: medical care, long-term care, mental health services, and aging network services These systems operate under different principles, and need to be coordinated in order to best serve older people;

§ Access Many mental health services

for older adults are consistently in short supply Some older citizens do not recognize their own need for help or do not know how to access the service delivery system Most older adults could access mental health care through their primary care physician, but many health professionals are not adequately prepared to identify or refer clients in need of mental health treatment;

§ Research An expanded mental health

and aging research agenda is needed to deepen our understanding of the biological, behavioral, social, and

cultural factors that prevent and cause

disease, especially for at-risk and

underserved populations Research is

needed in the areas of prevention,

intervention, health services, and

training;

§ Consumer involvement Consumer and

family participation are essential in the

care planning and treatment processes

Partnerships have begun to develop

among consumers and family members,

advocacy groups, and providers to plan

and develop mental health research,

systems, and services; and,

§ Needs of special populations To

provide competent assistance, mental

health professionals serving special

population groups such as racial and

ethnic minorities must acquire adequate

knowledge about the culture and values

of these groups, how services can be

tailored to meet the needs of these

groups, and what types of mental health approaches are most effective with minority elders

The report calls for the concerted efforts of those working to address the mental health needs of older persons This includes the public and private sectors, policymakers, practitioners, researchers, consumers, family members, and advocacy groups The opportunity to address these critical challenges is before us If we hesitate, our service delivery systems will be strained even further by the influx of aging baby boomers and by the needs of underserved older Americans

By building on the foundations that exist in the fields of mental health and aging, the upcoming crisis in geriatric mental health care can be transformed into an opportunity

to address the mental health needs of older adults

INTRODUCTION

Since 1900, the percentage of Americans

age 65 and over has tripled In 1998, they

numbered 34.4 million and represented

12.7% of the U.S population, or about one

in every eight persons America’s older

adult population will burgeon between the

years 2010 and 2030, when the 76 million

members of the “baby boom” generation

born between 1946-1964 reach 65 years of

age At that time, older persons will account

for 20% of the nation’s people (USDHHS,

1999a) The interplay of mental health and

aging issues, pointed out in the early 1970’s

by Butler and Lewis and others, may be

expected to become even more evident in

the future (Butler and Lewis, 1973) Based

upon studies that examine the existing

mental health needs of older Americans, it is

reasonable to anticipate that the upsurge in

the number of older adults in this new

century will be accompanied by an increased

need for mental health and supportive

services tailored to this population The

challenges that mental health and aging

policy makers and service providers are

already facing and may expect to confront in

the future can be readily identified

This report is written as a companion

document to Mental Health: A Report of the

Surgeon General (USDHHS, 1999a)

Because the original report provides an

excellent discussion of severe and persistent

mental disorders, this supplement focuses

upon major issues in the fields of mental

health and aging, discusses efforts to address

these issues, and identifies a range of

community resources, including those which

are acceptable to older Americans and their

families and may be brought to bear on their

behalf as they contend with mental health concerns

While substance misuse and abuse all too frequently go hand-in-hand with mental health problems, the primary focus of this report is limited to mental health It is acknowledged, however, that beyond concerns about the interaction effects of medications taken by older persons is a realm of issues related to substance misuse and abuse, including alcohol abuse, which merit full discussion

Just as the nation’s population is aging, so is

it becoming more diverse in terms of race and ethnicity Because minority populations have greater unmet need for mental health care and concomitantly are less likely to receive appropriate mental health services, mental health and aging professionals must also take into account the special needs of our growing ethnically and racially diverse older population Among the special needs that must be addressed are the challenges presented in serving persons with limited English proficiency A supplement to

Mental Health: A Report of the Surgeon General that will focus on mental health and

ethnic minorities is in preparation Because

it will examine the need for, use, and quality

of mental health services for distinct cultural groups and will include discussions

ethno-of issues pertinent to older adults in these each group, this supplement does not include a full discussion of these issues

CHAPTER 1 BACKGROUND

This chapter provides a discussion of issues

related to the mental health needs of older

Americans, including a demographic profile

of the nation’s elderly population, the

mental health problems that tend to be more

prevalent among them, mental health and

aging dilemmas that concern policy makers

as well as service providers, and efforts to

give heightened attention to these challenges

and to provide programmatic and policy

responses

Older Americans and Their

Characteristics

Older Americans are a diverse segment of

our nation’s population With the extension

of longevity, the diversity of older persons

in communities across the U.S has become

even more apparent Not only do the values,

beliefs, and activities of the old-old appear

to differ from those of the young old,

younger cohorts of older Americans also

include more persons of minority ethnicity

and race These differences foreshadow the

variations that can be anticipated within the

baby boom generation that will come of age

beginning in 2006

The following provides a brief description of

the older adult population in the United

States:

§ Age Older adults are often categorized

by their age: young-old (65-75), the old

(75-85), and the old-old (85+) The

older population itself is getting older

Persons 85 years and older comprise the

most rapidly growing segment of the

U.S population Among those older Americans are centenarians, numbering 65,000 in the year 2000 (U.S Bureau of the Census, 1996) While the extension

of longevity among older Americans is a result of public health and other successes, the incidence of chronic illness and vulnerability to mental health conditions such as depression and Alzheimer’s disease tends to rise in the later years of life While suicide rates for persons 65 and older are higher than for any other age group, the suicide rate for persons 85+ is the highest of all – nearly twice the overall national rate According to the Centers for Disease Control and Prevention, there are approximately 21 suicides per 100,000 persons among those 85 years of age and older (CDC, 1999) ;

§ Gender Most older persons and

especially the old and old-old are women At 65 - 69 years of age, there are 118 women for every 100 men At age 85+, there are 241 women for every

100 men (USDHHS, 1999b) According

to the U.S Census Bureau, four out of every five Americans 100 years of age and older are women (U.S Bureau of the Census, 1999) Women on average live seven years longer than men and are much more likely than older men to be widowed, to live alone, to be institutionalized (Goldstein & Perkins, 1993), and to receive a lower retirement income from all sources Because they live longer, women are also likely to suffer disproportionately from chronic disabilities and disorders, including

mental disorders However, white men

who are 85+ account for the high suicide

rate – 65 per 100,000 persons in the

elderly population (CDC, 1999)

One subsegment of the older adult

population – older gay men and lesbians

– have not been a focus of most

discussions about aging and mental

health Yet, the challenges faced by gay

men and lesbians have become more

widely known in recent years Though

there is a dearth of sound research on the

mental health needs of gay, lesbian, and

bisexual Americans, some have

suggested that these individuals may be

at increased risk for mental disorders and

mental health problems due to exposure

to societal stressors such as prejudice,

stigmatization, and anti-gay violence

(Dean et al, 2000) Social support—

which is an important element of mental

health for all older people—may be

especially critical for older people who

are gay, lesbian, or bisexual (Dean et al,

2000) Furthermore, access to health

care may be limited because of concerns

about health care providers’ sensitivity

to differences in sexual orientation

(Solarz, 1999) Further research on the

mental health needs of older gay,

lesbian, and bisexual Americans is

needed

§ Marital Status The emotional and

economic well-being of older Americans

is strongly linked to their marital status

At age 65-74, 79% of men and 55% of

women were married in 1998 These

numbers decrease significantly in the 8th

decade of life, with 50% of men married

and 13% of women married at age 85+

Among older Americans 85+, 42% of

men were widowers and 77% of women

were widows While only 4% of older

men and 5% of older women had never

married, all older persons who were alone because they were widowed, divorced (7%), or unmarried were more apt to live alone, to have a lower household income, and to have fewer caregivers available to assist them (Federal Interagency Forum on Aging Related Statistics, 2000);

§ Minority Status Minority populations

are expected to represent 25% of the elderly population in 2030, up from 16%

in 1998 Between 1998 and 2030, the white population 65 years and over is expected to increase by 79% compared with 226% for older minorities, including Hispanics (341%), African-Americans (130%), American Indians, Native Alaskans, and Aleuts (150%), and Asians and Pacific Islander Americans (323%) (USDHHS, 1999b) Minorities face additional stressors such

as higher rates of poverty and greater health problems (Sanchez, 1992) Despite this, access to health care is frequently frustrated by limited English proficiency and by the lack of availability of bilingual health care providers In a number of minority groups, Westernized mental health treatment modalities that tend to be dependent upon verbal inquiry, interaction, and response do not appear

to present a comfortable “fit” with many minority cultural beliefs and practices Consequently, minority communities have consistently called for assistance from persons who are bilingual and bicultural Where these are not available, there has been a call for mental health services and provided by professionals who have an understanding and appreciation for their cultural values, norms, and beliefs and are culturally competent;

§ Income A number of studies have

identified poverty to be a risk factor

associated with mental illness (Bruce &

McNamara, 1992; Cohen, 1989;

Sanchez, 1992) For those individuals

who are poor or who have limited

incomes, the lack of adequate financial

resources can seriously constrain access

to health and mental health services

While the economic status of older

Americans has improved, there is wide

disparity in the distribution of income,

especially among subgroups within the

elderly population (Siegel, 1996; U.S

Bureau of the Census, 1996) One of

every six (17.0%) older persons was

poor (below poverty level) or near-poor

in 1998 (USDHHS, 1999b) Among

older persons, women,

African-Americans, persons living alone, very

old persons, those living in rural areas,

or those with a combination of these

characteristics tend to be at greater risk

of poverty (Siegel, 1996) In fact,

divorced African American women who

are 65-74 years of age were among the

poorest of the poor in 1998, with a

poverty rate of 47% (Federal

Interagency Forum on Aging Related

Statistics, 2000);

§ Living Arrangements Living

arrangements are closely tied to income

and, specifically, being at risk of

poverty, health status, and the

availability of caregivers (Federal

Interagency Forum on Aging Related

Statistics, 2000) In 1998, the majority

(67%) of older Americans lived in the

community in a family setting with

spouses, children, siblings, relatives or

nonrelatives; however, this proportion

decreases with age Almost one-third of

those in the community lived alone and

were more likely to be at risk than those

who lived within family settings While

only a small percentage (4.2% or 1.43 million) of older persons lived in nursing homes in 1996, this percentage increases dramatically with age (USDHHS, 1999b) The majority of nursing home residents have such mental disorders as dementia, depression, or schizophrenia Moreover, a recent Supreme Court decision, Olmstead v L.C., requires states to provide community-based services for persons with disabilities—including mental disorders who would otherwise be entitled to institutional services, provided that community placement is appropriate, the affected persons do not oppose such a plan, and the placement can be reasonably carried out considering the resources of the state Thus, mental health services must

be designed to fit the needs of persons irrespective of their living arrangements.; and

§ Physical Health The majority of older

persons report that they are in good health compared with others their age (APA Working Group on the Older Adult, 1998) However, most older persons have at least one chronic condition and many have multiple conditions such as arthritis, hypertension, heart disease, cataracts, or diabetes In 1994-1995, over 4.4 million (14%) had difficulty in carrying out activities of daily living such as bathing

or eating and 6.5 million (21%) had difficulty with activities such as shopping, managing money, doing housework, or taking medication, many because of chronic disabling conditions Although poor physical health is a key risk factor for mental disorders (Kramer

et al, 1992), recent studies have established that all too often symptoms

of mental disorders escape detection and treatment by health professionals who

are treating older persons for physical

ailments Yet, the prevalence of chronic

conditions in the elderly population

should be a cause for anticipating

possible comorbidity Understanding

the relationships between physical and

mental health is a central task in the

assessment and treatment of older

persons by health care professionals

(APA Working Group on the Older

Adult, 1998) Moreover, potential

adverse effects of medications, and

specifically of drug interaction effects,

are more likely among older persons,

who tend as a group to use more

prescription drugs, and should thus be a

point of routine inquiry by health care

professionals

Successful Aging: Stressors

and Adaptations

During the normal process of aging, older

persons encounter stressors, such as

retirement from a career or job, that may

trigger both appropriate and distorted

emotional responses However, exposure

and adaptation to these stressors varies with

each person’s economic resources, gender,

ethnicity, level of education, life

experiences, and perception of the meaning

of the stressor itself Pearlin and Skaff

(1995) view older persons as confronted

with two main types of stressors: life events

and chronic strain, and their

conceptualization is used in discussing these

events

The life events thought to be the most

stressful are those that are unscheduled or

undesired rather than those that can be

planned for, such as a lack of an

occupational role in retirement As older

persons confront undesired life events, there

is an intricate balance of physical, social,

and emotional forces, any one of which can

upset or involve the others The initial event

or primary stressor may lead to secondary stressors such as those described below:

§ Health-Related Events Health events

such as a fall or a heart attack have been found to have a more depressive effect than many other types of events (Ensel, 1991; Murrell et al., 1988) For example, an elderly woman falls and breaks her hip, which necessitates hospitalization and surgery Upon her return home, she finds that stress proliferates as she needs help with shopping and the maintenance of her home, experiences economic strain, and

is unable to participate in leisure activities It may be difficult to distinguish the depressive effects of acute health events from the chronic problems that result from these events; and,

§ Loss of loved ones The loss of relatives,

friends, or a spouse during the advanced years of life can result in loneliness, an increased sense of vulnerability, increased isolation, and other psychosocial dilemmas Frequently adding to the emotional toll of bereavement is the need to also make practical decisions where to live, what

to do about the family home and possessions (Butler et al, 1998) Social roles may change, as can connections to friends, family, and community Some persons may gain a new sense of independence and competence (Lopata, 1979; Wortman & Silver, 1992) as they adapt to these losses and changes However, bereavement is a well-established risk factor for depression (Zisook & Shuchter, 1993; Zisook et al, 1994)

In addition to these unplanned life events,

chronic strains may also impact the older

adult (Pearlin & Skaff, 1995):

§ Strains related to their community or

neighborhood of residence Relocation

may place an older person in an

unfamiliar environment If the person

remains in his old neighborhood, the

older person may feel separated from

previous support networks because

familiar neighbors may no longer be

there A deteriorating or changing

neighborhood may be upsetting, and

access to transportation, convenience to

shopping and medical care, and

availability of a senior center or movie

theater are all amenities whose absence

may constitute ambient stressors Also,

growing frailty may leave people feeling

less able to defend themselves against

physical dangers;

§ Relationship strains These strains may

occur in relation to family members

Older people may experience

disappointments with regard to their

children’s situation in life, especially if it

does not coincide with their own values

or desires For example, their children

may not be raising their own children in

a way that meets with the elder’s

approval, or may not be supportive or

respectful of the older person

Additionally, assuming caregiving

responsibilities for a spouse may lead to

secondary stressors such as family

conflicts, financial strains, or the loss of

the caregiver’s identity Finally,

financial hardship and chronic health

problems may create undesired

dependency on others; and,

§ Strains in the older person’s immediate

environment These are the ordinary

logistical problems or “hassles” that

people face in their daily lives Studies

of the old-old who are living independently have focused attention on this class of stressors (Barer, 1993) They include such ordinary activities as getting out of the bathtub, managing the steps on a bus, seeing the fine print in a telephone book, changing a lightbulb, or removing trash for pickup For people

of advanced age these activities may be major obstacles to be overcome each and every day

Historically, our society has held ambivalent views of aging and of older persons Among these are many persistent myths that have resulted in the devaluation of the potential of older adults For example, the myth that older adults are set in their ways and incapable of learning, growth, and change does not take into account the fact that declines in some intellectual abilities generally are not severe enough to cause problems in daily living More importantly, such a myth disregards determinations by researchers that the aging brain has the capacity to make new connections, absorb new data and thus acquire new skills (Rowe and Kahn, 1998) Furthermore, it disregards recent analyses which have suggested that creativity is not lost in old age (Cohen, 2000)

Yet another myth incorrectly suggests that lack of productivity is associated with old age It miscasts older people as no longer capable of being productive on the job, of being socially active, or of being creative Instead, older adults are cast as disengaged, declining, and disinterested in life However, most older people tend to remain actively concerned about their personal and community relationships and many are still employed (APA Working Group on the Older Adult, 1998; Butler et al, 1998; Rowe and Kahn, 1998)

Acknowledging such myths is important in

order for communities to support the

self-esteem of older persons, their ability to live

and work successfully, and their ability and

motivation to maintain and improve the

quality of their lives Health, mental health,

human services, and aging programs will be

miscast if old age is perceived to be a time

of inevitable isolation, decline and decay

Thus, mental health and aging professionals

must be attentive to their biases and

stereotypes if they are to effectively serve

older persons (Roff and Atherton, 1989)

Recent research helps to further debunk

ageist stereotypes by revealing that older

persons as a group cope and adapt well and

tend to be very resilient This resilience is

comparable to and sometimes exceeds that

of their younger counterparts (Foster, 1997)

Older persons also appear to have the

capacity for constructive change, even in the

face of mental illness, adversity, and chronic

mental health problems (Cohen, 1988)

Whether older persons can face stressors,

function well, and maintain their well-being

appears to depend upon the resources that

older persons possess and use Several key

adaptive mechanisms used by older persons

have been identified (Pearlin and Skaff,

1995):

§ Coping Coping involves managing

situations giving rise to stress, managing

the meaning of these situations, and

managing the stresses resulting from

these situations Older persons tend to

use “emotion-focused coping,” a

strategy that refers to managing the

meaning of the situation or controlling

the symptoms of stress rather than trying

to manage the stressful situation itself

(Chiriboga, 1992; Martin et al., 1992)

Some of the stressors experienced by

older people such as frailty and chronic health problems are not easily modified

by problem-solving; thus, older persons may cope by reshaping the meaning of the situation or restructuring their priorities For example, an elderly woman who has painful arthritis and cannot tolerate the side effects of the medication is very disappointed that she can no longer play the piano She may choose to continue to enjoy music and to find satisfaction by coaching students Older persons also cope by universalizing their situation and comparing themselves with others, using family and friends as reference points This strategy helps them to see that hardships are not aimed solely at themselves, but also impact their peers;

§ Social support Social support includes

both concrete and emotional assistance provided by families, friends, neighbors, and volunteers or by acceptable private

or governmental organizations, including religious organizations and senior centers that have high levels of legitimacy within their community and their peer group For example, older persons may be active in church groups, supported by a circle of friends, or may receive concrete support in the form of homemaker or chore services and home-delivered meals when needed An extensive body of research has shown that social support is an important predictor of good physical and mental health, life satisfaction, and reduced risk

of institutionalization among older adults (LaGory & Fitzpatrick, 1992; Forster & Stoller, 1992; Sabin, 1993; and Steinbach, 1992) Social support may also buffer the adverse effects of various stressors common to aging (Feld & George, 1994; Krause & Borawski-Clark, 1994) Researchers point out

however, that the effectiveness of social

support depends on the situation, the

person, and his or her needs; thus,

goodness-of-fit is essential Unneeded,

unwanted, or the wrong type of support

may reduce older persons’ independence

or self-esteem (Pearlin and Skaff, 1995;

Rowe and Kahn, 1998); and,

§ Sense of control Many older people are

able to maintain a sense of mastery over

the circumstances of their lives and this

sense extends into late life as a resource

important to well-being (Rodin, 1986)

Those working with older persons can

reinforce this sense of control by

respecting their right to make decisions

or to initiate, withdraw, or terminate

treatment (APA Working Group on the

Older Adult, 1998) A sense of control

has also been found to be an effective

buffer mitigating the impact of stressors

(Cohen & Edwards, 1989; Krause &

Stryker, 1984) For example, in

Alzheimer’s caregivers, a strong sense of

mastery protects the caregiver against

the stressors arising in the daily care of

the patient (Skaff, 1991)

In their study of older persons who are

functioning at a high level, Rowe and Kahn

(1998) found three characteristics that define

successful aging: (1) low risk of disease and

disease-related disability; (2) high mental

and physical function; and (3) active

engagement with life And they found that

successful aging is most fully represented by

the combination of all three of these factors

However, Pearlin and Skaff (1995) remind

us that the outcome of successful aging must

be examined not only in relation to the

above three criteria, but with respect to the

social, economic, and cultural conditions to

which people are exposed as well as their

adaptive mechanisms This psychosocial

perspective assures that we acknowledge the

diversity of older persons and view each individual as having unique interactions with his or her environment

Ideally, aging is a dynamic process in which

an individual confronts the stressors and challenges of later life not as a passive victim but as an actor drawing on resources developed over a lifetime Even the impact

of losses that may be irreversible, such as those that involve personal health and the deaths of significant others, can be minimized by restructuring personal meaning, with the availability and use of social supports, and a sense of mastery over important circumstances of life (Pearlin & Skaff, 1995)

The Mental Health of Older Americans

Most older adults enjoy good mental health, but almost 20% of those who are 55 years and older experience specific mental disorders that are not part of "normal” aging The most common disorders, in order of prevalence, are anxiety disorders, such as phobias and obsessive-compulsive disorder; severe cognitive impairment, including Alzheimer’s disease; and mood disorders, such as depression Schizophrenia and personality disorders are less common (USDHHS, 1999a)

There are suggestions, however, that mental disorders in older adults are underreported One study, for example, estimates that 8-20 percent of older adults in the community and

up to 37 percent of those who receive primary care experience symptoms of depression It is particularly noteworthy that the rate of suicide, frequently a consequence

of depression, is highest among older adults (Hoyert et al, 1999) In addition, approximately two-thirds of those in nursing homes suffer from mental disorders,

including Alzheimer’s and related dementias

(Burns et al, 1993)

Older adults with mental illness vary widely

with respect to the onset of their disorders

Some have suffered from serious and

persistent mental illness most of their adult

life, while others have had periodic episodes

of mental illness A substantial number

experience mental health disorders or

problems for the first time late in life—

problems which are frequently exacerbated

by bereavement or other losses which tend

to occur in old age Yet another variable is

severity Mental disorders can range from

problematic to disabling to fatal

Clearly, then, treatment and prevention

efforts must take into consideration the

range of experiences and needs of older

adults with mental disorders in order to

provide appropriate care for older persons at

all points of the mental health continuum

But there are major barriers to overcome

For example, assessment and diagnosis of

mental disorders in older people can be

particularly difficult (USDHHS, 1999)

Older people with mental disorders may

present with different symptoms than

younger people—emphasizing somatic

complaints rather than psychological

troubles (USDHHS, 1999) In addition, it

can be hard to determine whether certain

symptoms—like sleep disturbances—are

indicative of mental disorders or another

health problem (Lebowitz et al, 1997)

Moreover, there is significant

underdiagnosis of mental illness among

primary care providers A survey of primary

care physicians found that just over half felt

confident in diagnosing depression, and only

35% felt confident in prescribing

antidepressant medications to older people

(Callahan et al, 1992)

Treatment also presents a number of challenges Older people metabolize medications differently due to physiological changes, which may make them more vulnerable to side effects of psychoactive medications They are also likely to be taking medications for other disorders, placing them at risk for unintended medication interactions Older adults with cognitive deficits may also have difficulty managing medications or remembering appointments (USDHHS, 1999) Psychosocial interventions can be an important component of effective treatment, but lack of transportation may make it difficult to get to counseling appointments

or support group meetings As noted earlier, there is convincing evidence that depression and other mental disorders typically are unrecognized and thus fail to be treated by primary care providers

Efforts to prevent mental disorders among older adults have also been inadequate At this time, there is no national agenda to promote mental health and prevent mental and behavioral disorders (Center for Mental Health Services [CMHS], 2000) Present knowledge about effective prevention techniques is not as extensive as is our understanding of the diagnosis and treatment

of mental disorders Preventing mental disorders before they occur—or primary prevention requires some understanding of their etiology, risk factors, pathogenesis, and course (USDHHS, 1999) As noted in a

1994 Institute of Medicine (IOM) report, the base of knowledge about prevention for some disorders is considerably more advanced than for others (Mrazek & Haggerty, 1994) Among older adults, for example, the largest pool of primary prevention research focuses on depression that develops late in life (USDHHS, 1999) Moreover, there has been a history of disagreement within the mental health

community about how to define prevention

(Mrazek & Haggerty, 1994) Nonetheless,

there has been a growing awareness that

certain psychosocial factors can heighten the

risk of developing mental disorders or

exacerbate them when they occur Further

research is needed on the prevention of

mental disorders in older adults In addition,

greater effort must be devoted to translating

research advances that have already been

made into practice

Delivery of Mental Health

Services to Older Adults

While there is strong evidence of the need

by older persons of mental health services,

older adults have made limited use of these

services (Demmler, 1998) It is estimated

that only half of all older adults who

acknowledge mental health problems

actually are treated by either mental health

professionals or primary care physicians

(Blazer et al, 1988) A very small

percentage of older adults – less than 3%

report seeing mental health professionals for

treatment This rate of utilization is lower

than for any other adult age group (Lebowitz

et al, 1997) Older Americans account for

only 7% of all inpatient services, 6% of

community-based mental health services,

and 9% of private psychiatric care, despite

comprising 13% of the U.S population

(Persky, 1998) And, in a study examining

community mental health services and older

persons, 40 percent of community mental

health providers identified

non-health-related services such as transportation and

home help services as unmet needs,

suggesting that the comprehensive needs of

these persons are not being met (Estes et al,

1994)

Unfortunately, individual and systemic

barriers thwart the provision and receipt of

adequate care to older persons with mental

health needs The following are among the barriers most frequently noted in the literature (Birren, et al, 1992; Butler et al, 1998; Estes, 1995; NCOA, 1999; Persky, 1998):

§ Stigma Stigma surrounding the receipt

of mental health treatment affects older people disproportionately (USDHHS, 1999a), and as a result, older adults and their family members often do not want

to be identified with the traditional mental health system The stigmatization of mental illness has deep, historical roots dating back to Descartes’ conceptualization of the separation of mind and body During centuries past, the stigma surrounding mental illness was reinforced in both European and American societies by fears about deviant, violent behaviors While considerable progress has been made to achieve increased scientific understanding of mental disorders, the social meanings attached to mental illness and the treatment of most conditions continue to place the moral identity of the individual at risk of degradation Today’s older Americans grew up during decades in which institutionalization in asylums, electroshock treatments, and other treatment approaches, understandably, were regarded with fear Moreover, among older persons who tend to be defined in large measure by their pre-retirement work roles and by any ongoing community involvement, the possibility of becoming more vulnerable, falling victim to ageist perspectives, and then being doubly jeopardized and demeaned can only raise the specter of a

loss of dignity and of place in society

§ Denial of problems Anxiety,

depression, memory loss, and dementia

may complicate the ability of older

persons to recognize that they have a

mental health problem for which they

should seek help However, mental

health problems may also be denied

Health professionals, family members,

and policy makers may internalize

society’s negative attitudes toward older

persons and give superficial attention to

or be dismissive of their problems

Moreover, as older persons themselves

become more dependent, they may fear a

loss of control over their lives and thus

become resistant to the idea that they

may need help;

§ Access barriers Access to services by

older persons is thwarted in a number of

ways Affordable, accessible

transportation to services may be

unavailable For some older people, the

cost of mental health treatment—

especially prescription drugs may be

too expensive Older persons who live

alone are a particularly hard-to-reach

population They may live in rural areas

that do not have adequate mental health

services, or they may live near services

but far from family members They may

not be able to come to an office as a

result of their physical frailty The

isolation of older adults means that

outreach workers who go into the home

may be needed to build relationships and

provide day-to-day monitoring and

support Outreach activities may also

involve approaching the family of the

elder, but the only “family” may be

neighbors or a service coordinator; for

example, in a public housing project;

§ Funding issues Typically, funding

streams for aging and mental health are

separate and limited As in other fields

of health and human services, the

separation of funding streams can

complicate efforts to collaborate and can result in the fragmentation of services Perhaps of greater concern to most service providers, families, and older persons with mental health problems is the fact that current funding for both of these systems is not ample enough to cover the mental health service needs of the elderly population While Medicare and Medicaid provide insurance coverage for older person’s mental health needs, these benefits are limited;

§ Lack of collaboration and coordination

The mental health and aging networks are separate and distinct in most state and local communities across the nation Coordination issues are thus as relevant

in mental health and aging as in other fields of health and human services Although interdisciplinary practice and coordination have long been advocated, there has been a continuing need to emphasize their importance and to ensure that they occur Interdisciplinary collaboration and the coordination of multiple services are especially essential

in work with elders who are poor, have limited English proficiency, or physical health problems

§ Gaps in services While the mental

health system has tended to not serve older persons in quite the same proportion as children or adults, the Aging Network has tended, in relation to mental health and aging, to serve primarily persons with Alzheimer’s disease Even when community-based service providers have the capacity to respond to the mental health concerns of older adults, they frequently are challenged by the lack of adequate reimbursement and by the lack of a complement of staff needed to provide appropriate, culturally sensitive

prevention and treatment services to

minority elders and continuing care to

those who are chronically mentally ill

§ Workforce issues There are national

shortages of health and social service

professional and paraprofessional

personnel who have expertise in

providing geriatric mental health care

Shortages across disciplines are sure to

become even more problematic as the

population ages and the demand for

specialized mental health services

increase For example, presently, there

are 200-700 geropsychologists and 2,425

board-certified geriatric psychiatrists

One promising trend has been noted

General psychiatrists are seeing a greater

proportion of geriatric patients in their

practices In 1996, 18% of psychiatrists

had a geriatric caseload in excess of

20%; this represented an increase of

148% and 25% from 1982 and 1989

respectively (Colenda et al, 1999)

However, this does not come close to

meeting the projected need for at least

5,000 in each psychiatry and psychology

specialty (Jeste et al, 1997) Moreover,

less than 5 percent of members of the

National Association of Social Workers

identify their primary focus of practice

as Aging (Gibelman & Schervish, 1997),

and only 15 percent of clients of direct

service social workers in mental health

are 60 years of age and older, although

the proportion of elders estimated to

have mental health problems is 20-22

percent (Gatz & Smyer, 1992) A

survey of state home health associations

found low to moderate availability of

home health aides who serve primarily

older adults Despite the fact that many

older adults in need of home health

services have complex physical and

mental problems, few home health

workers had any aging-related education (Dawson & Santos, 2000)

Thus, there is a critical need for training opportunities for those entering and currently working in the area of mental health and aging Surveys suggest that

53 percent of graduate social work programs have no fieldwork faculty in aging and 21 percent have no classroom faculty (Dye, 1993; Mellor & Solomon, 1992) And, of 637 nursing baccalaureate programs, only about 14 percent have required training content in gerontological nursing (Dye, 1993; O’Neal, 1994) Barriers to education include a lack of trained faculty, lack of training sites, student and faculty resistance, curricula that are too full, and

a view of the elderly as a low-priority

population

§ Organized consumer support At the

state, local and national levels, there has been recent success in organizing consumer groups that include older persons who are consumers of mental health and/or substance abuse services, their families, and advocates, but

expansion of these efforts is needed

Although these important service delivery issues and the critical challenges mentioned

at the outset of this chapter continue to remain concerns, there have been strong, though intermittent, efforts to give heightened attention to mental health and aging issues and to develop and provide programmatic and policy responses

Advances in Mental Health and

Aging

Despite the lack of a sustained nationwide

emphasis on mental health and aging, there

have been a number of notable endeavors

and initiatives and a strong and abiding

commitment to advance the agenda among a

cadre of leaders in mental health and aging

In 1973, a groundbreaking text, Aging and

Mental Health, was published Co-authored

by geropsychiatrist Dr Robert Butler, the

first Director of the National Institute on

Aging and the author of the Pulitzer Prize

winning treatise on aging and older persons,

Why Survive?, and Myrna Lewis, a

psychiatric social worker whose specialty is

work with older persons, it cast a spotlight

on aging and mental health issues The

nation’s aging and mental health policy and

practice landscape were drawn for public

and professional discussion, the latter

pursued in earlier years by a small but

influential, multidisciplinary group of

experts

At the federal level, this was followed by the

establishment in 1978 of the President’s

Commission on Mental Health, due to the

personal advocacy of First Lady Rosalynn

Carter The Commission appointed a task

panel specifically to study the needs of older

Americans Among the recommendations of

the panel were expanded outreach efforts to

elders with mental health needs; enhancing

Medicare reimbursement for

community-based mental health services; expansion of

training programs for geriatric mental health

professionals; improved access to home

health care; and accelerating scientific

research into dementia The task panel set

forth an agenda for mental health and aging

that continues to resonate today

Since then, there has been a wide range of

innovations and initiatives, such as the

identification and dissemination of key program and policy issues, conduct of important research studies, the development

of guidelines for clinical practice, and the formation of national, state, and local coalitions and older adult consumer groups Many of these efforts have been supported and implemented with funds from foundations and federal, state, and local governments More recent developments, a few of which are highlighted below, serve as

a foundation for a significant, sustained, and concerted effort to address the mental health needs of older people:

Collaboration

Coalition Building There is a growing

number of mental health and aging coalitions engaged in efforts to improve the availability and quality of mental health preventive and treatment services to older Americans and their families through education, research, and increased public awareness At the national level, the National Coalition on Mental Health and Aging (NCMHA), which has been in existence since 1991, includes in its membership thirty-seven national organizations In 1994, the Coalition published a practical guide on how to build state and community mental health and aging coalitions (NCMHA, 1994) The Coalition has developed an Action Plan for mental health and aging utilizing the work that was done at the Coalition’s conference meeting in 1999 (NCMHA, 1999)

During the mid-1990’s the Substance Abuse and Mental Health Services Administration (SAMHSA) funded two coalition-building initiatives that were implemented by the American Association for Retired Persons (AARP) and by the National Association of State Mental Health Program Directors (NASMHPD) for the purpose of identifying,

designing, and training networks of older

adults, mental health service providers, and

advocates to build mental health and aging

coalitions at the state level The goal of

these coalitions was to increase public

awareness of mental health and aging issues

while improving the provision of mental

health services to older adults (NTAC,

1997) Again, in 1998, SAMHSA funded a

similar project implemented by AARP This

activity included both state and local

coalitions and both primary care and

substance abuse in the coalition process

As a result of these and other independent

efforts, there are approximately 35 state and

10 local coalitions Furthermore, SAMHSA

is currently funding a project through AARP

that will review and analyze the results of

earlier coalition-building activities to

identify factors that contribute to successes

and failures Technical assistance materials

will be developed to facilitate

coalition-building in additional states;

Medicare Coordination of Care

Demonstration As a result of the Balanced

Budget Act of 1997, HCFA is conducting a

demonstration to test the effectiveness of

coordinating care for chronically ill

fee-for-service Medicare beneficiaries The study

will examine the impact of coordination on

clinical outcomes, client satisfaction, quality

of life, and the appropriate use of covered

services (HCFA, 2000) The demonstration

will be conducted in at least nine sites and

will focus on chronic conditions which

represent high costs to Medicare, and which

are amenable to care management Four of

the eleven targeted conditions are mental

health conditions including psychoses,

Alzheimer’s disease, alcohol and drug

abuse, and depression Participating

beneficiaries will receive interventions to

improve self-care, identify complications

early, avoid hospitalization, and better

coordinate treatments and medications for

multiple conditions The demonstrations will

be independently evaluated Demonstration awards will be made in early 2001;

Consumer Involvement

Consumer Involvement In May 1998, older

mental health consumers ranging in age from 60-87 gathered in Washington DC to organize a group to voice their concerns and

to promote awareness of the need for home- and community-based services This meeting was convened by the Judge David

L Bazelon Center for Mental Health Law and financed by the Center for Mental Health Services (CMHS), the Retirement Research Foundation, and the Nathan Cummings Foundation The conference brought together 31 consumers from 27 states and representatives from advocacy organizations and caregivers In May 2000,

a second meeting of these older consumers, also convened by the Bazelon Center and supported by CMHS, resulted in the formation of the Older Adult Consumers of Mental Health Alliance (OACMHA) The main purpose of OACMHA is to improve the quality of and access to mental health services for older adults OACMHA plans

to organize state and local chapters that will advocate for older persons with mental health needs (Bazelon Center, 2000);

Public Awareness and Education

Surgeon General’s Initiatives: In

December, 1999, Mental Health: A Report

of the Surgeon General was released

(USDHHS, 1999a) This groundbreaking report, the result of collaboration between the Center for Mental Health Services and the National Institute of Mental Health, provides an up-to-date review of scientific advances in research on mental health and mental illness and calls upon communities, agencies, policy makers, employers, and

citizens to take concerted action The report

includes a chapter entitled, “Older Adults

and Mental Health” that reviews normal

developmental milestones of aging,

discusses mental disorders in older persons,

identifies mental health interventions, and

points out obstacles in the delivery of

services A summary of this chapter is

included in the Appendix of this report

Furthermore, the Surgeon General’s report

also documented the extent to which

members of diverse ethno-cultural groups

are less likely to receive appropriate mental

health care than are members of the

population as a whole and the extent of

unmet mental health needs As a result, a

supplement to the first report that will focus

on mental health and ethnic minorities is

currently being written by staff from

SAMHSA’s Center for Mental Health

Services, the National Institute of Mental

Health, and the Office of the Surgeon

General It will summarize available

knowledge on the unmet need for mental

health care among minority groups across

the life span, including minority older

adults, and discuss promising directions for

improved research and services

Also in 1999, the Surgeon General unveiled

The Surgeon General's Call To Action To

Prevent Suicide This document sets forth a

number of steps that can be taken by

individuals, communities, organizations and

policymakers to prevent suicide, and served

as a precursor for the National Suicide

Prevention Strategy, which the Surgeon

General plans to release in 2001;

White House Mini-Conference on Emerging

Issues in Mental Health and Aging In

February, 1995, a Mini-Conference

sponsored by the National Coalition on

Mental Health and Aging was held prior to

the White House Conference on Aging

(WHCoA) A set of resolutions was developed and introduced at the WHCoA (Gatz, 1995) and served as the primary document from which the final Mental Health and Aging resolution evolved Furthermore, the white papers that were prepared for the Mini-Conference were

published under the title Emerging Issues in

Mental Health and Aging (Gatz, 1995);

White House Conference on Mental Health

On June 7, 1999, the first White House Conference on Mental Health was held in Washington D.C This conference brought together consumers, advocates, researchers, and business and medical professionals to discuss mental health issues that affect over

50 million Americans The conference examined issues such as mental health research, pharmacology, service delivery, and insurance coverage;

Education Toolkit SAMHSA and the

National Council on Aging (NCOA), with the assistance of the Administration on Aging, are developing an Education Kit that will enable aging services organizations such as senior centers, meal programs, and senior housing organizations to conduct educational programs for staff and clients on substance abuse and mental health issues for older adults This kit will include educational materials (e.g video, brochure),

a step-by-step implementation guide, and a Community Linkages Manual containing information about 16 local and state programs that exemplify best practices with regard to the establishment of linkages between aging and substance abuse and aging and mental health organizations The kit is scheduled for release in 2001;

Nursing Home Comparisons As discussed

later in this report, many nursing home residents suffer from mental disorders In an effort to increase nursing home

accountability, HCFA has posted data about

the number and types of staff at individual

nursing homes, each facility’s care and

safety record, records of deficiencies found

by state survey agencies, facility ownership,

and ratings of each facility in comparison to

state and national averages on the new

Nursing Home Compare Internet site at

www.medicare.gov The information

provided on this site allows consumers to

search by zip code or by name for

information on each of the 16,500 nursing

homes participating in Medicaid or

Medicare and to consider the comparative

potential for quality of life and mental health

as a consequence of care provided in various

nursing homes;

Seniors and the Internet One way that

older Americans can keep abreast of health

information and communicate with family

and friends is by using the Internet Older

persons have made it clear that they can use

the Internet and that they do not want to be

left behind in the Information Age Several

studies have examined computer training

programs for older adults One of these, a

Train-the-Trainer project implemented by

the Setting Priorities for Retirement Years

(SPRY) Foundation (1998) found that the

training had a positive impact on seniors’

confidence in using computers and the

Internet, in conducting consumer health

information searches online, and in sharing

health care information with doctors,

families, and friends Another study (Cody

et al, 1999) found that those who learned to

surf the Internet had more positive attitudes

toward aging, higher levels of perceived

social support, and higher levels of

connectivity with others This suggests that

more attention needs to be paid to the mental

health implications of connectivity via

computers and the Internet in the older adult

population;

Research

Mental Health and Aging Research Three

major multi-site studies are currently evaluating strategies for the treatment of mental disorders in older primary care patients The National Institute of Mental Health supports the Prevention of Suicide in the Primary Care Elderly Collaborative Trial (PROSPECT) study (Bruce & Pearson, 1999), and the Hartford Foundation and the California HealthCare Foundation are funding Improving Mood: Promoting Access to Collaborative Treatment for Late Life Depression (IMPACT) (Hartford Foundation, 2000a) These studies are comparing the effectiveness of traditional models of care with service delivery models

in which treatment for depression and other risk factors for suicide is delivered within primary care practices by mental health specialists

Through the Primary Care Research in Substance Abuse and Mental Health for Elders Study (PRISMe), the Substance Abuse and Mental Health Services Administration (SAMHSA), the Department

of Veterans Affairs, the Health Resources and Services Administration, and the Health Care Financing Administration are evaluating the relative effectiveness of integrated mental health services delivered

to older persons in the medical care setting They are comparing the effectiveness of these services versus the referral of these same persons to mental health professionals outside the primary care setting All of the foregoing studies are testing the effects of interventions in relation to an array of outcomes including functioning, general health outcomes, health-related quality of life, and health care use (Harvard Coordination Center, 2000)

Another important large-scale multi-site

study, the Clinical Antipsychotic Trials of

Intervention Effectiveness project (CATIE)

(NIMH, 2000), is designed to evaluate the

clinical effectiveness of atypical

antipsychotics in the treatment of 450

outpatients with Alzheimer’s disease

Funded by NIMH, the study is a

randomized, parallel group, double-blinded

study comparing treatment using three

antipsychotic drugs and a placebo in

Alzheimer’s patients with delusions or

hallucinations and/or clinically significant

aggression or agitation;

Outcome and Performance Measures

Funded by SAMHSA, the State Indicator

Pilot Grant project involves 16 state mental

health authorities in the piloting of 32

performance measures over a three-year

period Indicators, focused on mental heath

service provision in the participating states,

cover the four domains of access, quality or

appropriateness, outcome, and

plan/management Data are gathered by

age, gender race/ethnicity, and diagnosis

State grantees will report on these

performance indicators in 2001 There are

plans to complete a comparative analysis of

the data on the states

The New Hampshire (NH) Dartmouth

Outcomes-Based Treatment Plan (OBTPA)

for Older Adults Tool Kit (NH-Dartmouth

Psychiatric Research Center, 1999)

developed with support from the New

Hampshire Health Care Fund, Community

Grant Program and the Robert Wood

Johnson Foundation includes a variety of

instruments that integrate assessment,

treatment planning, and outcome

measurement for older adults in the

community with chronic mental health

concerns The tools included in the kit

consist of an Assessment Toolkit, a

Treatment Planning Guide and Outcomes

Checklist This instrument was piloted in three states and is currently being used and administered statewide through New Hampshire’s Office of Community Mental Health Administration;

Workforce Issues

Education and Training Under the

sponsorship of the John A Hartford Foundation, an Aging and Health Program is funding a variety of initiatives in academic geriatrics and training (Hartford Foundation, 2000b) In 1994, the Foundation implemented a Geriatric Interdisciplinary Team Training Program to train clinicians in teamwork and collaboration, with the aim of improving the effectiveness of interdisciplinary care By 2000, over 2,500 trainees in 17 disciplines had completed the program The Foundation has also established an Institute for the Advancement

of Geriatric Nursing Practice at New York University’s School of Education’s Division

of Nursing to train nurses in geriatrics Outstanding junior medical faculty conducting aging research are supported for

a three-year period by individual awards from the Foundation’s Paul Beeson Physician Scholars in Aging Research Program Finally, the Foundation supports the Strengthening Geriatric Social Work Initiative an effort to build a consensus on standards for geriatric social work education, create a cadre of faculty members committed to research and teaching about the needs of older adults, and developing geriatric field training sites (Hartford Foundation, 2000c)

In addition, the Bureau of Health Professions, Health Resources and Services Administration, has issued a series of reports outlining a national agenda for geriatric education These reports detail the state of the art and set forth recommendations for

improving geriatric education for a wide

variety of professions, including dentistry,

nursing, medicine, public health, and social

work (Bureau of Health Professions, 1995);

The HCFA Nursing Home Staffing Study A

groundbreaking study released by HCFA in

August, 2000 indicated a strong association

between staffing levels in nursing homes

and quality of care (De Parle, 2000) For the

first time, it points to a clear, statistically

valid relationship between staffing levels

and quality of care It found that, on

average, serious erosion of quality of care

occurs when care falls below certain

minimum ratios – 2 hours per resident day

for nurses’ aides, 45 minutes per resident

day for total licensed staff (RNs and LPNs),

and 12 minutes per resident day for RNs

More than half of the nation’s nursing

facilities (54 percent) were below the

suggested minimum staffing level for

nurses’ aides, nearly one in four (23 percent)

were below the suggested minimum staffing

level for total licensed staff, and nearly a

third (31 percent) were below this same

level for RNs This has particular mental

health implications because many nursing

home residents suffer from mental disorders

Future plans call for the expansion of

research efforts beyond the initial study;

Clinical Practice Several professional

organizations have convened consensus

conferences and issued practice guidelines

for the diagnosis and treatment of late-life

depression (Katz, 1996) and Alzheimer’s

disease and related dementias (Rabins, P,

1998; Small et al, 1997) The American

Association for Geriatric Psychiatry

(AAGP) has produced a set of guidelines for

primary care physicians to use in

determining whether to refer older people

with depression to a geriatric psychiatrist

The group recommends referral when there

is uncertainty over the diagnosis, when symptoms are especially severe, when the patient is at high risk of harming himself or others, when treatment is complicated, or for maintenance management (AAGP, 1997) Furthermore, Volume 29, No 1 of

Professional Psychology: Research and Practice, published by the American

Psychological Association, contains a series

of articles that review the knowledge base needed in work with older adults (APA Working Group on the Older Adult, 1998) The articles include discussions about training in geropsychology (Qualls, 1998), and provide guidelines for the assessment of competency and capacity of the older adult (Baker et al, 1998);

As the discussion in this chapter notes, the older adult population has unmet mental health needs that are expected to rise in number as the number of older persons grows dramatically over the next 30 years The chapters that follow discuss supportive services, primary care, and mental health services in relation to older persons at risk of

or contending with mental disorders Considerable attention is given to the variety

of community-based resources that are already acceptable access points for information, referral, and supportive assistance among older adults and their families Provided that system barriers can

be removed, these may be particularly helpful to persons with several types of mental health needs, including persons with serious mental illness who previously resided in institutions; those who develop serious mental illnesses later in life; and those who have mental health problems, but have not been diagnosed with serious mental illness

CHAPTER 2 COMMUNITY MENTAL HEALTH SERVICES

The mental health system is comprised of a

full spectrum of public and private sector,

community-based, and institutional services

The specialty mental health services system

consists of private mental health providers

funded by private insurance and consumers,

and publicly and privately owned providers

funded by states, counties, and

municipalities Institutional or

facility-based mental health services include

inpatient care (acute and long-term),

residential treatment centers, and therapeutic

group homes Community-based services

include outpatient psychotherapy, partial

hospitalization/day treatment, crisis services,

case management, and home-based and

“wraparound” services These services are

often tailored to respond to the specific

needs of a community; for example,

programs in rural areas may offer mental

health outreach programs Many

community-based organizations, as part of

their charter, provide services regardless of

an individual’s ability to pay

Unfortunately, community mental health

organizations generally tend to underserve

older people (Jeste et al, 1999)

Historically, public and private funding for

adult mental health services has been

targeted toward costly, intensive

institutional care However, over the last

several years national and state policies to

increase home and community-based health

and human services, such as efforts to

further downsize psychiatric hospitals, have

reflected a continuing interest in shifting

clients to community mental health services (Demmler, 1998) As an example, the Nursing Home Reform Act of 1987 specifically seeks to decrease the likelihood

of transinstitutionalization, or the recycling

of former mental patients into other forms of institutional care To accomplish this, it mandated Pre-Admission Screening and Annual Resident Review (PASRR) for all potential and existing nursing home residents PASRR helps to ensure adequate identification of the mental health needs of nursing home residents and to exclude from nursing homes individuals who are more appropriately treated elsewhere—either in the community or in another type of institution (USDHHS, 1999) Moreover, over the last two decades, due mainly to court decisions calling for the care of persons with mental illness in least restrictive environments, states and communities have sought to reorder their service priorities away from institutional care and toward the provision of community-based services in more home-like settings

This chapter acknowledges this trend and focuses on these community-based mental health services The principles of community mental health practice include the following: (1) services should be accessible and culturally sensitive to those who seek treatment; (2) services should be accountable to the entire community, including the at-risk and underserved; (3) services should be comprehensive, flexible, and coordinated; (4) continuity of care should be assured; and (5) treatment providers should utilize a multidisciplinary

team approach to care (Sands, 1991; Stroul,

1988)

How do community mental health

systems address mental health

needs?

Community-based mental health services

address both acute and chronic mental health

needs Outpatient individual or group

counseling aims to improve personal and

social functioning through the purposeful

use of psychotherapy, behavioral therapy or

medications (CMHS & NIMH) Day

treatment may be appropriate for persons

who are able to reside in the community and

receive therapeutic and rehabilitative care

Emergency services are available on a

24-hour basis through telephone crisis lines,

walk-in treatment, or agencies specially

designated to provide emergency care

Intensive outpatient services are provided

through partial hospitalization for those with

severe and persistent mental disorders

(SPMD) and for others who may thus be

able to avoid relapse and/or hospitalization

(NCCBH, 2000)

Inpatient services, often provided at

community hospitals, offer short-term

intensive treatment Psychosocial

rehabilitation is offered to those with

SPMDs who may benefit from any

combination of educational or vocational

training or other transitional services

Residential programs run the gamut from

transitional facilities where individuals

recently discharged from hospitals are

treated and supervised in a community

setting, to houses that provide an

opportunity for independent living And,

specialized services may be geared to a

particular group; for example, mental health

outreach programs may focus on increasing

access to care for older persons (NCCBH,

2000)

The need for primary and secondary prevention is also addressed by community mental health systems through early casefinding and intervention, education and community consultation, rehabilitation, and psychotherapy (NCCBH, 2000)

How are community mental health systems implemented?

Most mental health funding comes from state and local governments, Medicaid, and private insurance Today, more than two-

thirds of the funding for the overall public

mental health system – nearly $10 billion –

is provided by the states, while Medicaid (with a mix of Federal, state and county contributions) provides an additional 22 percent Medicare and other Federal spending provide about 7 percent, and private health insurance accounts for 4 percent (NCCBH, 2000) Chapter 5 describes Medicare and Medicaid mental health benefits in more detail While Medicare provides only minimal support to the public mental health system, it is a major source of overall mental health funding Publicly funded services generally are intended to serve as a “safety net” for those who are unable to afford private insurance

or to pay for services The federal government augments state and local funding through the Community Mental Health Services Block Grant (CMHSBG) The CMHSBG is a joint Federal-state partnership that awards annual formula grants to the states to provide community-based mental health services to adults with serious mental illness and children with serious emotional disturbance The Substance Abuse and Mental Health Services Administration’s (SAMHSA) Center for Mental Health Services administers the CMHSBG